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Some inmates should have the right to euthanasia

Should convicted prisoners facing life behind bars get the right to die on the grounds of their tortured existence? Sometimes, says a doctor who has experienced the treatment of inmates who have attempted suicide

By Christian Brown

After decades behind bars, Frank Van Den Bleeken has been granted the right to die under Belgium’s euthanasia laws

(Image: Virginie Lefour/Belga/Press Association Images)

In high-security prisons the world over, small numbers of prisoners are serving lifelong sentences, deprived of all but the minimum of human contact and confined for most of the day to their cells.

One such inmate is murderer and rapist Frank Van Den Bleeken, who has just won the right to die on the grounds of mental anguish after three decades behind bars in Belgium. A panel of medical experts granted his request under the country’s euthanasia law, creating controversy there and in countries such as the UK, where the debate on assisted suicide is gathering pace.

Some argue that it can be rational to commit suicide – and for the purposes of this article, we will consider “rational suicide” to mean acts which are voluntary and informed, and where the individual is shown to have mental capacity. If one accepts this argument, it is hard to imagine a more powerful circumstance in which to kill oneself than that of a life sentence.

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Suicide rates among convicted prisoners are around six times that of the general male population, according to the World Health Organization. The suicide rate of long-term inmates also seems to increase with length of stay; “lifers” seem to be at a particularly high risk. Of course, a proportion of these cases will not meet the criteria for rational suicide, but others will.

The essence of the “right to die” debate in general seems to be about the limits on circumstances in which it is ethically permissible to take one’s own life. At the uncontroversial end of the spectrum, consider a terminally ill great-grandfather who has lived life to the full, has made final contact with everyone he wishes to say goodbye to, and then chooses to self-administer a fatal dose of morphine with the goal of ending his intolerable and intractable pain.

Stakeholders

On the other hand, there are a great many scenarios in which suicide could cause significant harm to others – let’s call these people “stakeholders” in the life of the suicidal individual. Consider the effect of suicide on the young children of a single parent, or the depressed and unstable patients of a psychotherapist. In these cases, you might well argue that a voluntary decision to commit suicide while fully aware of such consequences would be unethical.

So where do convicted criminals fit in? Who are the stakeholders, and why might they want them to remain alive? The most important are probably&colon; the victim/family of the victim, relatives of the convict, and society at large. It is conceivable that the family of the victim may have found solace in the knowledge that the offender has been locked up and is suffering. They too “depend” on the convict remaining alive.

Would this be a good enough reason to prevent a lifer from killing themselves? I’m uncomfortable with the idea that satisfaction gained through the suffering of another is a “good” justification for keeping them alive against their will. Of course, there’s the opposite situation in which stakeholders would rather the prisoner die – but this doesn’t go very far in justifying the ending of their life.

As a member of a medical team faced with suicidal inmates, I usually felt uneasy. The role of the prison doctor can seem to be to facilitate, or prolong the duration, of the patient’s suffering. It isn’t like treating the terminally ill in hospital. When we resuscitate someone who has cancer, perform palliative radiotherapy and administer painkillers and other medication, we’re trying to remove the detrimental immediate effects of the illness, such that they can make the most of the rest of their lives.

Renewing the disease

In resuscitating a prisoner, we are simply returning the patient to the condition which manifested itself in the “symptom” of suicidal behaviour. There are no medical conditions in which the desired end point of the treatment is to re-establish the underlying pathology in this way. The role of doctors is often challenged by end-of-life issues, but in this instance, the function of caregiver, healer or alleviator of suffering seems to be detrimentally subverted. A case from 2002 illustrated a successful attempt by a prisoner to secure a do-not-resuscitate order, following a gruesome and sustained suicide attempt.

So far, I’ve considered situations in which individuals have already attempted suicide. However, there may be parallels to be drawn between the criteria we use to justify assisted dying in the context of terminal illness, and a hypothetical system for use with some prisoners. Let’s say we only consider convicts who can be shown to be indisputably guilty of their crimes. Then we should ask whether they are likely to die in prison, whether they have any evidence of mental illness or have full mental capacity, and whether their desire to end their life is sustained and consistent. The final point encapsulates their subjective evaluation of dying versus the life they expect to be able to lead.

Of course, the conclusions here only follow in a system where very long or indefinite prison sentences exist, the acceptability of which warrants an altogether different discussion. The first port of call should be to try and make prison an environment which doesn’t lead to suicidal behaviour – a system in which death becomes the preferable option hardly screams “humane”.

Saying this, there may be some minor practical benefits to facilitating inmates’ rational suicide – for example, saving the cost of maintaining an individual who will never leave the prison system. But more importantly, for a small number of convicts such as Frank Van Den Bleeken, an undignified and torturous existence serving a life of suicidal solitude could be avoided.

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Christian Brown is a junior doctor with an interest in psychiatry and ethics. This article is adapted from his 2013 post on the right of inmates to die, for the University of Oxford's Practical Ethics blog